APPLICATION CUM DECLARATION FORM

For Health Check up at HealthSpring

I,Shri/Smt/Ms._________________________________________________________________
Membership No. _____________ wish to avail the Health check up facility
provided by our Bank at HealthSpring Centers.

I hereby declare that “I have read the terms & conditions of the “Medical
checkup scheme” and fully understood that The Greater Bombay Co-op. Bank
Ltd is not responsible for the services of the Center or for the results of the
test”.
This facility is extended to me as a Member / Employee of the Bank with a sole
objective of welfare of the Members / Employee and Bank has no statutory
obligation in implementation of the scheme.
1. Tel/Mobile No.: ______________________2. Date of Birth: ______________________

3. Email Address:______________________________________________________________

4. Sex : Male Female 5. Preferred Date of Appointment: ______________

6. Please select any one of the following package:

Standard CHC Package (As per the annexure) (40 years and above)
Exclusive Male Package (Standard Package + PSA Test)
Exclusive Female Package (Standard Package+ PAP Smear Test +
Mammography Test)
(Exclusive Packages are for Members who are 50 years and above)
7. Center where check up is to be done : ____________________________________
(Kindly check the annexure for name and details of the Centers)

Signature of the Applicant : ______________________________

** Note : Kindly enclose Copy of PAN Card or any Age Proof. Original documents as
stated above to be produced for verification at the Branch. All the tests are to be done
at one single Center only. Members/Employees are advised to carry the Appointment
Letter, ID Proof and List of Tests as per the CHC Package to the Clinics.

For Branch Purpose Only

Branch Stamp with Signature: Branch Receipt Date : _________________

 “TERMS AND CONDITIONS”

THINGS YOU NEED TO REMEMBER PRIOR TO HEALTH CHECK-UP

 Health Checks are done through prior appointments only.

 Shareholders are requested to kindly observe the appointment timings, to

facilitate the smooth flow of their Health Check.

 Shareholders are requested to carry their appointment letter duly signed by the
Authorized Signatory along with ID Proof bearing Date of Birth and List of Tests
provided to you. No Health Check-Up will be done without the above mentioned
documents.

 Shareholders are requested to visit the branch of HelathSpring originally opted by

them at the time of application.

 The employee undergoing the health check-up should reach between 8.15 am –
9.30 am or as scheduled by the clinic.

 Minimum of 12 hours fasting is essential prior to the health check-up.

 May drink water during fasting. Refrain from alcohol at least 48 hours prior to the
health check-up.

 Men are requested to shave their chest to ensure a good ECG / Tread Mill Test.

 If you are wearing contact lenses, please remove those 2 days prior to health
check-up.

 Wear loose clothing, no jewelry (Necklaces / Chains) and easily removable

footwear.

 If you are diabetic, avoid taking your insulin injections / anti diabetic tablets on
the morning of Health Check-up. Please carry your insulin / anti diabetic tablets
which you can have before or after your breakfast in the clinic. Other regular
medication can be taken as instructed by the doctor. Please carry regular
medication along.

 Please bring all your earlier (Within 1Year) medical records and medical
accessories like glasses, hearing aid if you have any when you come for Health
Check Up.

 In case of any additional Tests / Investigations / Procedures / Consultations at

request or if required will be charged separately to the shareholders as per the
standard rates by the Clinic.

 Please do not carry urine sample as the same will be collected at the centre on
the day of checkup.
 Standard Exclusive
Package Package
Annual Health Check Program 40 years 50 years
and and
above above
Heart Rate Yes Yes
Oxygen Saturation Yes Yes
Blood Pressure Yes Yes
Key Vitals
Hip:Waist Yes Yes
Height, Weight & Body Mass Index (BMI) Yes Yes
Blood Group & Rh factor Yes Yes

CBC (16 parameters include Total Leucocytes, Eosinophils,

Basophils, Lymphocytes, Monocytes, Hematocrit (PCV), Total
RBC Count, Hemoglobin, Mean Corpuscular Volume, Mean
Infection Yes Yes
Corpuscular, Hemoglobin, MCH Concentration, Red Cell
Distribution Width, Platelet Count, Platelet Distribution Width &
Mean Platelet Volume)

ESR Yes Yes

Screening
Routine Urine Analysis Yes Yes

Diabeties Blood Sugar (Fasting) Yes Yes

Screening
Blood Sugar (Post prandial) Yes Yes
Comprehensive Lipid Profile (Total Cholesterol/ HDL Cholesterol/
LDL Cholesterol/ Choi: HDL ratio/ LDL: HDL ratio/ VLDL Yes Yes
Cardiovascular Cholesterol/ Triglyceride)
risk check ECG (Electro Cardio Gram) Yes Yes
Chest Xray Yes Yes
Kidney Health Basic Renal Profile - BUN / Creatinine / Uric Acid /Serum Yes Yes
Liver Health Basic Liver Profile (SGPT / SGOT / Bilirubin) Yes Yes
Thyroid Profile - T3 / T4 / TSH Yes Yes
Radiology & Routine Eye checkup - by Physician at Centre & Vision Test -
other Yes Yes
investigations Near, Far& Color
Routine Dental checkup - by Physician at Centre Yes Yes
PAP Smear for Female, 50 years and above No Yes
Cancer Check Mammography for Female, 50 years and above No Yes
PSA for Male, and above No Yes
Breakfast at Centre Yes Yes

Physician Consultations / Gynecologist Consultation (For

Womens) with review and roadmap to good health (30-45mins) Yes Yes
Consultations after Health Check-up
Additional Dietician Consultation to drive improved medical
Yes Yes
outcome

EMR (Electronic Medical Record) - Your medical records will be

accessible from anywhere, anytime. Kindly contact your Yes Yes
HealthSpring Center for further details.
Tele-Health: 24*7 High-quality, protocol-lead un-limited doctor
consultations for routine health issues & Emergency
Note for Consultations. Saves patient time and ensures he/she gets
Yes Yes
Members: timely, reliable and actionable medical advice. You can directly
contact the Help Line Numbers - 1800 266 5222 / 8652886529
for any details.
Home Collection - (Exclusive Package Services) - Enjoy peace of
mind while giving samples at home as Healthspring brings you Yes Yes
the complete assurance of hygiene anywhere, anytime.
Sr.No. Center Name Address Phone Number

Shop No 17, Ground floor,Mittal Industrial Estate,

1 Andheri East Building No 2, Marol Naka,Andheri Kurla Road, 022 6129 0303
Andheri (East), Mumbai -400059
Shree Krishna, G Wing- 104, First floor,Opposite
2 Andheri West Laxmi Industrial Estate,Near Fun Republic,New Link 022 6131 4141
Road, Oshiwara,Andheri (W), Mumbai - 400053

207/208 Ground Floor,Allied Building,St John's Road 022 2658 6767 /

3 Bandra and St Andrew's Road,Pali Hill, Bandra (West), Emg -
Mumbai - 400050.Landmark - Near Gold's Gym 8433939685

Shree Rameshwar CHS LTD Tower A,Next to

4 Borivali Gokhale School,Shimpoli Road, Borivali 022 2968 6161
West,Mumbai - 400092
Shop No. 1, Ground Floor,Saideep - 17, Old Cuffe
5 Cuffe Parade 022 2217 4545
Parade,Mumbai - 400 005
Shiv Kutir, Opposite Hotel Amigo,VS Marg, Shivaji
6 Dadar 022 2446 4646
Park,Dadar, Mumbai – 400 028
Shop No 6, Skye Enclave,Ground Floor, Tilak
7 Ghatkopar Road,MP Vaidya Marg, Ghatkopar (East),Mumbai - 022 2501 8484
400077.Landmark - Opposite Cafe Coffee Day.
Shop No 1 & 2, 1st Floor, Onkar CHS Ltd,Shivdham 022 6130 3535 /
8 Goregaon Sankul, Gen AK Vaidy Marg,Opp. Oberoi Mall, Emg -
Goregaon (E),Mumbai - 400097. 7738897527
Ground Floor, Plot No 12,Rain Basera, Main
9 Juhu Gulmohar Road No 1,JVPD Scheme, Mumbai - 022 2621 5050
400049.Landmark - Near Sujay Hospital
Shop No 49, 50 & 51, Ground Floor,Jupiter Co -
operative Housing Society,Opp. Rama’s
10 Kandivali 022 2846 4949
Restaurant,Evershine Millennium Paradise,Thakur
Village, Kandivali (East),Mumbai – 400 101
2nd floor, Advani Chambers,August Kranti
11 Kemps Corner 022 6748 3636
Marg,Kemps Corner, Mumbai 400 036.
101, Glacis Tower, Linking Road,Above Indusind
12 Khar 022 6604 3737
Bank, Khar (W),Mumbai 400052
Shop 1,2 & 3, Ground Floor,Moreshwar Complex,
13 Kharghar Plot no. 35,Sector - 21, Kharghar,Navi Mumbai - 022 2776 3030
410210 Landmark - Shilp Chowk
Shop No 1 & 2, Satyam Tower CHS Plot 18 Sector 20
14 Koparkhairane Koparkhairane Navi Mumbai - 400709 Next to 022 2755 5353
Zaikaa Restaurant
Casa Reo, Lodha Palava,Kalyan - Shilphta 0251 6696 593 /
15 Lodha Palava
Road,Usarghar Gaon, Thane, Mumbai 421201 9579564735
Unit No. 102-B, Palm Court ComplexM Building,
16 Malad Above D MartLink Road, Malad (W), Mumbai - 400 022 6133 6464
064
Shop Nos. 1, 2 and 3, Ground floor “Munish C.H.S.
17 Mulund Ltd, LBS Marg, opp. Johnson & Johnson Factory, 022 6787 4444
Mulund (West), Mumbai – 400 080
Shop No. 20, Ground Floor Meredien Apartments,
18 Nerul Sector 6 Nerul, Navi Mumbai, 400706 Nerul 022 2771 7720
Landmark: Near Direct2u Grocery Store
Bayside Arcade, Shop No. 11, Near Ashok Towers,
19 Parel 022 6192 4343
Opp Bharat Mata Cinema, Parel, Mumbai - 400012
Galleria - 205/205A, 2nd Floor, Opposite KFC, Powai,
20 Powai 022 6744 3838
Mumbai - 400076
 No. 19, Ground floor, Bhoomi Paradise,Sector-11,
21 Sanpada Sanpada (E), Navi Mumbai – 400705 Landmark: 022 2775 6363
Near Millenium Towers. Near Juinagar station.
Orion Business Park, Shop No. 9, Ground Floor,
Thane
22 Ghodbunder Road, Near Cine Wonder Mall, 022 4129 4242
Ghodbunder
Manpada, Thane (W) - 400607
Ground Floor, B - Wing, Mohan Heritage, Almedia
Thane
23 Road, Panchpakhadi, Thane West - 400602. 022 2549 7474
Panchpakhadi
Landmark - TMC Office
G1, G2, G3 & G4, Ground Floor, A - Wing, P P
Paradise, Ambadi Road, Village Navghar, Taluka
24 Vasai Road 0250 2333001
Vasai, District Palghar. Mumbai 401404 Landmark -
Next to Vasai Gurudwara.
Shop No. 12 and 13, Ganesh Co.Op. Housing
25 Vashi 022 6744 3939
Society, Sector1, Vashi, Navi Mumbai - 400703

Members / Employees opting for Exclusive Package will be given special

service for Home Collection.
Home
26 Members / Employees opting for Exclusive Package are requested to
Collection
mention the nearest Health Spring Center in the form while opting for
Home Collection.